Localization of Brain Stem Lesions

Anatomy of the Brain Stem

Part of the brain that extends from:
The rostral plane of the Superior Colliculus To the caudal end of the Medulla Oblongata at the Foramen Magnum
Contains Structures: Midbrain Pons Medulla Oblongata

Brain Stem anterior view 1. Optic chiasm 2. Optic nerve 3. Optic tract 4. Medial sulcus of the crus cerebri 5. Oculomotor nerve 6. Pons 7. Pyramidal eminence of the pons 8. Retroolivary fossa 9. Oliva 10. Posterolateral sulcus 11. Decusssation of the pyramids 12. Anterolateral sulcus 13. Lateral funiculus 14. Pyramid 15. Foramen caecum 16. Middle cerebellar pedunculus 17. Trigeminal nerve 18. Crus cerebri 19. Interpeduncular fossa, posterior perforate substance 20. Mammillary body 21. Tuber cinereum 22. Infundibulum

Posterior view of the brain stem

1.Pineal gland 2.Thalamus ( Pulvinar ) 3.Superior colliculus 4.Inferior colliculus 5.Lemniscal trigone 6.Frenulum veli 7.Superior medullary velum 8.Median sulcus 9.Gracile tubercle 10.Cuneate tubercle 11.Posterior intermediate sulcus 12.Posteromedian sulcus 13.Vagal trigone 14.Hypoglossal trigone 15.Striae medullares 16.Facial colliculus 17.Locus coeruleus 18.Parabrachial recess 19.Crus cerebri 20.Inferior collicular brachium 21.Medial geniculate body 22.Lateral geniculate body 23.Suoerior collicular brachium 24.Habenula 25.Habenular commissure

Brain Stem lateral view

1. Medial geniculate body 2. Inferior collicular brachium 3. Superior colliculus 4. Inferior colliculus 5. Superior cerebellar peduncle 6. Rhomboid Fossa 7. Gracile fascicle 8. Cuneate fascicle 9. Lateral funiculus 10. Pyramid 11. Posterolateral sulcus 12. Oliva 13. Retroolivary fossa 14. Bulbopontine sulcus 15. Pons 16. Trigeminal nerve 17. Lateral sulcus of the crus cerebri 18. Pontomesencephalic sulcus 19. Crus cerebri 20. Optic nerve 21. Optic tract 22. Lateral geniculate body 23. Leminiscal trigone 24. Middle cerebellar peduncle 25. Inferior cerebellar peduncle
5

Medulla Oblongata (Myelencephalon)

Most caudal Portion of the brainstem Extends from

The Rostral border of the Pons

Rostral to the emergence of the first spinal roots Join with the spinal cord at the Foramen Magnum

Vascular supply
Barainstems large regional arteries
Has three types of branches

Para median branches: supplying midline structures Short circumferential: supply ventrolateral & lateral surface Long circumferential: Supply posterior structures & Cerebellum
10

Brain stem arteries - anterior view

1. Posterior cerebral artery 2. Superior cerebellar artery 3. Pontine branches of the basilar artery 4. Anterior inferior cerebellar artery 5. Internal auditory artery 6. Vertebral artery 7. Posterior inferior cerebellar a. 8. Anterior spinal artery 9. Basilar artery

11

Para median Bulbar branches (Para median portion) Vertebral artery and Anterior spinal artery 1. Hypoglossal Nucleus 2. Medial longitudinal fascicules 3. The pyramids 4. Inferior Olivary Nucleus (medial part)

Lateral bulbar branches (Lateral portion) Intracranial vertebral artery fourth segment or the Posterior inferior Cerebellar artery Occasionally the basilar artery or the anterior Inferior Cerebellar artery

12

Medullary syndromes
Medial Medullary Syndrome Cause:1. Occlusion of ( vertebral a.), (anterior spinal a.), (basilar a. lower segment)
2.Vertebrobasilar dissection 3.Dolichoectasia of the vertebrobasilar system 4. Embolism and meningovascular syphilis
13

Anterior Spinal a. occlusion (Slide 7) Ipsilateral pyramid, medial lemniscus, hypoglossal nerve Clinical Picture: 1. Ipsilateral paresis, atrophy and fibrallation of the tongue the protruded tongue deviates toward the lesion(HN) (away from the hemiplegia 2. Contra lateral hemiplegia (Py) (face is spared) 3. Contra lateral loss of position and vibration sense (ML) Pain and temperature spared spinothalamic tract is not affected 4. Occasional upbeat nystagmus (MLF involvement ) Bilateral involvemnt gives 1. Quadriparesis 2. Bilateral LMN lesion of the tongue 3. Complete loss position and vibration sense
14

Occasionally:
1. 2. 3.

4.

HN can be spared In Anterior spinal artery occlusion. Only the pyramids can be damaged giving Pure motor hemiplegia Central facial paresis Corticobulbar fibers descend ipsilaterally before crossing to the facial nucelus of the other side. Crossed motor hemiparesis Lesions of lower medulla of the crossed fibers of the arm and uncrosseds fibers of to the leg.

Lateral Medulllary Syndrome( Wallenberg) Intracranial vertebral artery or posterior inferior cerebellar artery occlusion Causes: 1. Spontaneous discection of the vertebral artery 2. Medullary neoplasms Usually metastasis 3. Cocaine abuse 4. Abscess 5. Demyelinating disease 6. Radionecrosis, Hematoma, trauma, neck manipulations
15

Characteristic Clinical Picture are:

Results of wedge shaped damage to the lateral medulla
Ipsilateral facial hypalgesia & thermoanestesia (Trigeminal spinal n.and tract) Ipsilateral facial pain 2. Contra lateral trunk & extremity hypalgesia & thermoanesthesial (due to Spinothalmic tract) 3. Ipsilatral palatal pharyngeal and vocal cord paralysis wit dysphagia and dysarthria (Nucleus Ambiguus) 4. Ipsilatral Horners syndrome (Descending sympathetic fibers) 5. Vertigo, nausea, and vomiting (Vestibular nuclei) 6. Ipsilateral Cerebellar signs (Inferior cerebellar peduncle and cerebellum) 7. Occasionally Hiccups (Medullary respiratory centers) Diplopia (Lower Pons) Rostral medulla( Severe dysphagia, Hoarsness of voice , Facial paresis) Caudal medulla (Marked vertigo, nystagmus, gait ataxia)09
1.

16

Rare manifestatios of Wallenbergs Syndrome: 1. Wild arm ataxia ( Lateral Cuneate n.) 2. Ipsilateral limb cllumsiness ( Subolivary area) 3. Central pain associated with allodynia 4. Contralateral hyperhydrosis with ipsilatral anhydrosis 5. Inability to sneeze ( Spinal n.of trigeminal N.) 6. Loss of taste (N.Tractus Solitarius) lateral zone 7. Autonomic dysfunction ( N.Tractus Solitarius Medial caudal zone) 8. Failure of Automatic breating( n. Ambigiuus adjecent Reticular Formation) Ocular motor abnormalities: 1. Dysfunction of ocular alignment ( Otolithic vestibular n. damage) Elevation of the contralateral eye with out vertical displacement of the ipsilatral eye. Rssulting in diplopia, head tilt , environmental tilt 2. Torsional nystagmus 3. Nystagmus 4. Smooth pursuit and gaze holding abnormality( Cerebe;ar FlloculusParaaflloculusassoing through the inferior peduncle. 5. Lateropulsion or ipsupulsion 6. Abnormalities of saccades (Cerebellum Amplitudes control not speed ) patients 17 have contralateral hypometra and ipsilateral hypermetra

Other lesions
1.

2.

3.

4. 5.

6.

Isolated vertigo with ipsilatral lateropulsion of the trunk (Medial branch of PICA) Bilateral cerebellar infarction (PICA) Vertigo, Nystagmus Retropullsion,ataxia,upsidedown vision) Babinski-Nageotte syndrome (Hemimedullary syndrome) L+M syndrome Intracranial vertebral a. Tegmeental medullary lesion Medullary satiety Opalski syndrome LM synd. Ipsilateral hemiplegia Lower med. Lesion f corticospinal tract after pramidal decusation Lateral pontomedullary syndrome LM synd. + Pontine findigs (Vll +VIII nerves smptoms
18

THE PONS

Anatomy of the Pons

Part of metencephalon Extending caudal plane of striae medullaris posteriorly To pontomedullar sulcus anteriorly Inferrior colliculus dorsally and cerebellar peduncles ventrally Dorsal part referred as Tegmentum Ventral part as Basis pontis or Ponto cerebellar portion Contains Cranial Nerve nuclei,Fiber tracts

19

20

21

Vascular supply Paramedian Vessels 4-6 in number arising from the Basilar a. supply Medial basal pons, pontine nuclei cortico spinal fibers medial leminiscus
Short circumferential a. arise from Basilar a. enter the brachium pontis supply Ventrolateral basis pontis

Long circumferential Superior cerebellar a.. Arise from Basilar a. Suply : the dorsolateral pons Brachium pontis Dorsal Retiular formation Periaquidctal region Ventrolateral pontine tegmentum occasionaliy Anterior inferior cerebellar a. arise mostly from the basilar a. supply: lateral tegmentum of the lower two thirds of the pons Ventrolateral cerebellum Internal auditory a. arise from Basilar a. Supply: Auditory ,Facial , vestibular Ns
22

Pontine Syndromes
Ventral pontine syndrome (Millard Gubler syndrome) Lesion of the ventrocaudal pons Involves basis pontis And fascicles of cranial nerves Vll,Vl
1.

Raymond syndrome Lesion of the ventromedial pons Affects ipsilaterl Vl N Corticospinal tract Spares Vll N.

2.

3.

Contralateral hemiplegia (Pyramidal tract) Ipsiaeral lateral rectus paresis wit diplopia Ipsilateral peripheral facial paresis

1. 2.

Ipsilateral rectus paresis Contralateral hemiplegia sparing the face (Pyramidal tract)

23

Pure Motor Hemiparesis Lacunar infarcts in the basis pontis Involving the corticospinal tract Motor hemiparesis without facial involvement Other lesions that can give similar findings: internal capsule (Po. Limb) Cerebral peduncle Medullary pyramid Vertigo ,dysartira, & gait abnormality favor pontine lesions

Dysarthria-Clumsy hand syndrome Vascular leions in the basis pontis At the junction of the upper one third and the lower two thirds Usually lacunar lesions Facial weakness Severe dysarthria Dysphagia Clumsiness and paresis of the hand Similar findings in: Genu of the internal capsule Deep cerebellar hemorhage
24

Ataxic Hemipresis Lesions basis pontis (U1/3 +L2/3) Lacunar lesions mostly Homolateral ataxia & crural paresis More severe in the lower limb Occasional :Dysarthria, nystagmus, paresthesia Similar findings in: Thalamocapsular lesions Contralat. post.limb. of int. capsule Contralat. Red nucleus Superficial infarcts in the territory of superficial ant.cerebral a. Para central area

Locked in syndrome Bilateral ventral pontine lesion Due to: Infarction. Tumor. Trauma. Haemorrhage. Central pontine myelinolysis 1. Quadriplegia Cort.Sp. Lesions bilat. 2. Aphasia involvement of Cort.Bul. Fibers the lower cranial nerve n. 3. Occ. Involvement of Vll N fascicles Patient is fully awake NO damage to the Reticular Formation or supranuclear oculomotoor pathway
25

Dorsal Pontine Syndrome

Foville sndrome Involves dorsa pontine tegmentum In the caudal third of the pons It consists of: 1. Contralateral hemiplegia due to corticospinal tract invovment 2. Ipsilateral facial palsy Vll N 3. Inabality to move te eye conjugately to ipsilateral side due to Vl N. or paramedian pontine Reticular formation Raymond-Cestan-Chenais syndrome Rostral lesion of the dorsal pons It consists of : Cerbellar signs Ataxia it coarse Rubral tremors Contralatral sensory modalities are reduced ( medial lemniscus & spinothalamic tract) Ventral extension contralateral hemiparesis (corticospinal tract)

1.

2.

3.

26

Paramedian Pontine syndrome

Several clinical syndromes exist 1. Unilateral mediobasal infarcts wit Facio-bracio-crual hemiparesis Dysarthria &and homolateral or bilateral ataxia
2.

Unilateral mediolatral basal infarcts: ataxia dysarthria slight hemiparesis , ataxic hemiparesis or clumsy hand dysarthria syndrome

Unilateral mediocentral or mediotegmental infarcts Clumsy hand dysarthria syndrome Ataxic hemiparesis Without sensory or eye movt disoders hemiparesis with contralateral facial or abducens palsy 4. Bilateral centrobasal infarcts Pseudobulbar palsy & bilateral sensorimotor disturbance Common causes are Small vessel disease, vertebrobasilar large vessel disease & Cardiac embolism less commmonly
3

27

Lateral Pontine syndrome

Marie_Foix Syndrome Lesions affecting the brachium pontis Isilatral cerebelar ataxia ( celebellar connections) Contralatral hemiparesis ( corticospinal tracts) Contralatral hemianesthesia for pain and tempature ( spinothalamic tracts)

Others

28

The mesencephalon
Anatomy of the mesencephalon
Rostrally Superior Colliculus-Mamillary body plane Caudally the plane just caudal to the Inferior Colliculus Divided in to: dorsal Tectum the tegmentum and the cerebral peduncle Contains ascending and descending tracts reticular nuclei and well delinated nuclear mases

29

30

31

32

Vascular supply of the Mecencephalon

Includes Paramedian and Circumferential vessels Paramedian vessels Arise from the origins of the Posterior Cerebral a. 1. Thalamoperforating (supplying the thalmus 2. Pedunclar ( supplying the media peduncle) (Midbrain tegmentum including Oculomotor n. the Red n. & SN) Circumferential a. Circumferential perpendicular aa. 1. Quadrigemnial aa.(from PCA supply Sup. & Inf. Colliculi) 2. Superior cerebellar aa. (Supply Cerebral pedunclesBrachium conjunctivum, superior cerebelum) 3. Posterior chroidal aa. (supply Cereberal Peduncle lat.sup. Colliculi, Thalamus,Choroid Plexus of the third ventricle) 4. Anterior Choroidal aa.( From Int. Carotid or MCA) Cerebrl peduncle & supramecencephalic structure 33 5. Posterior Cerebral aa ( Gives branch to Mecencephalic vesels)

Mesencephalic Syndromes
Ventral Cranial Nerve lll Fascicular Syndrome (Weber) Lesion Cerebral Peduncle esp. medial peduncle May damage pyramidal fibers Fascicle of third nerve Consists of: Contralateral Hemiplegia including te lower face(CoS CoB) Ipsilateral oculomotor paresis + parasymp. Cranial N. /// (Dilated pupil)

Dorsal Cranial N /// faciclular syndrome(Benedikt) Lesion affecting the tegmentum May affect Brachium conj., Red n. Cranial N. /// Consists of: Ipsilateral oculomotor paredis wit dilated pupil Contralatera Involuntary movt like intention temor ,hemichorea, hemiatetosis (Destruction Red n.) Dorsal Red n lesions = Brachium conj. Can give similar findings (Claude synd.)

34

Dorsal Mesencephalic syndromes Mainly neuroophthalmologic abnormalities (Sylvian aqueduct synd. Parinaud synd.) Commonly seen in: Hydrocephalus Tumors of Pineal origin Consists of : 1. Paralysis of conj. Upward gaze (downward occ.) 2. Pupillary abnormality( usu,Large 3. Convergence retraction Nystagmus o upward gaze 4. Pathalogic lid retractionColliers sign 5. Lid lag 6. Pseudo abducens palsy

Top of the Basilar Syndrome Oclusive vascular disease rostral BA Usually embolic Giant aneurysms Vasculits Cerbral angiography Gives infarction of: mid brain thalamus portion of temporal and occipital lobe

Consists of : 1. Disorders of eye movt 2. Pupillary abnormality 3. Behavioral abnormality 4. Visual field defects 5. Motor and sensory deficits
35